Healthcare Provider Details

I. General information

NPI: 1659051324
Provider Name (Legal Business Name): SHELITA WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6113 ORANGE AVE
LONG BEACH CA
90805-3042
US

IV. Provider business mailing address

5200 CLARK AVE UNIT 216
LAKEWOOD CA
90714-7012
US

V. Phone/Fax

Practice location:
  • Phone: 562-313-1801
  • Fax:
Mailing address:
  • Phone: 562-313-1801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberKK321310
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberKK321310
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberKK321310
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberKK321310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: